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23 July 2014 - Case of the Week #320

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Case of the Week #320

Clinical History:
A 30 year old man presented with phimosis. A white plaque lesion was noted on his glans penis, measuring 0.7 x 0.6 cm in size, which was biopsied.

Micro images:

What is your diagnosis?

Balanitis xerotica obliterans

Balanitis xerotica obliterans, also known as lichen sclerosus of genitalia, is the male equivalent of lichen sclerosus et atrophicus of the vulva, a chronic and atrophic mucocutaneous condition. It is the most common cause of pathological phimosis in boys, and may also cause narrowing of the urethral meatus and paraphimosis. It also affects middle-aged men.

Clinically, it presents as a gray-white, irregular geographic foci of atrophy in the inner foreskin, glans or perimeatal area, with variable erosion, ulceration and raised pearly white areas. Microscopy shows a thinning or thickening of epidermis with orthokeratotic hyperkeratosis. There is also lamina propria thickening and loss of structures due to edema, sclerosis or hyalinization. The basal layer shows vacuolar degeneration, accompanied by diffuse fibrosis and a deep lymphocytic infiltrate. Atypical cases may have epithelial changes of penile intraepithelial neoplasia (PeIN), usually differentiated.

Due to the association with low grade keratinizing squamous cell carcinoma (Am J Surg Pathol 2003;27:1448, Am J Surg Pathol 2004;28:895, BJU Int 2013;111:970), biopsy is recommended if not resolved after circumcision (BJU Int 2006;98:74), and by other authors in all cases (J Urol 2007;178:2268).

Nat Pernick, M.D., President
and Shivani Thakore, Associate Medical Editor
PathologyOutlines.com, Inc.
30100 Telegraph Road, Suite 408
Bingham Farms, Michigan (USA) 48025
Telephone: 248/646-0325
Email: NatPernick@Hotmail.com
Alternate email: NatPernick@gmail.com